Driver/Vehicle Declaration

DRIVER / VEHICLE DECLARATION – Due to changes in Duty Of Disclosure, we require that you complete this form at renewal of your motor vehicle policy.

If you answer ‘yes’ to any of the questions about the registered owners or nominated drivers, you must provide details. If you answer ‘no’ to roadworthiness, or ‘yes’ to modifications, you must also provide details.

QUESTIONS ABOUT THE REGISTERED OWNERS & NOMINATED DRIVERS

In the last 12 months, has the registered owner or any nominated driver:

Had a motor accident or loss, a vehicle burnt or stolen or made a claim under a motor insurance policy? (regardless of whom was at fault). * Had a motor accident or loss, a vehicle burnt or stolen or made a claim under a motor insurance policy? (regardless of whom was at fault). * yes no

Had a speeding fine and/or any other motoring conviction or prosecution including camera offences but excluding parking infringements? * Had a speeding fine and/or any other motoring conviction or prosecution including camera offences but excluding parking infringements? * yes no

Had their licence cancelled, suspended or special conditions imposed? * Had their licence cancelled, suspended or special conditions imposed? * yes no

Had any insurance declined or cancelled, been refused renewal of any insurance, had special terms, conditions or excesses imposed, or had a claim refused? * Had any insurance declined or cancelled, been refused renewal of any insurance, had special terms, conditions or excesses imposed, or had a claim refused? * yes no

Had a conviction for driving under the influence of alcohol or drugs? * Had a conviction for driving under the influence of alcohol or drugs? * yes no

Has the registered owner or any nominated driver ever: Been convicted of or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property? * Has the registered owner or any nominated driver ever: Been convicted of or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property? * yes no

Been declared bankrupt and not been discharged within the last 12 months? * Been declared bankrupt and not been discharged within the last 12 months? * yes no

Suffer / suffered from any physical or mental disability or medical condition or are any dependent on any drug or medication which could affect their driving performance? * Suffer / suffered from any physical or mental disability or medical condition or are any dependent on any drug or medication which could affect their driving performance? * yes no

Been convicted of or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property? * Been convicted of or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property? * yes no

Is the vehicle roadworthy? * Is the vehicle roadworthy? * yes no

Has the vehicle had any modifications? * Has the vehicle had any modifications? * yes no

If you answered yes, please list details

Name of Insured

Email address

Date

Name of Person who completed this form: *

Policy Number: *

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